At the corner of Makaloa St
and Kaheka St, in Honolulu

Schedule an Appointment | (808) 591-1566

Contact Us
- Appointment Request
About Us
Eye Care Services
Eyeglasses
Contact Lenses
- Contact Lenses for Astigmatism
- Contact Lenses FAQ
Insurance
Online Forms

At the corner of Makaloa St
and Kaheka St, in Honolulu

Schedule an Appointment | (808) 591-1566

Contact Us
- Appointment Request
About Us
Eye Care Services
Eyeglasses
Contact Lenses
- Contact Lenses for Astigmatism
- Contact Lenses FAQ
Insurance
Online Forms

Home

Patient Registration Form

Patient Registration Form

Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

Patient Information

First Name*

Last Name*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone Number *

Please provide a telephone number, with area code, so we can contact you.

Daytime Phone

Cell Phone

Email Address *

Personal Information

Gender

Female Male

Date of Birth *

Social Security Number (last 4 digits only!)

Preferred Language *

Race *

Ethnicity *

Marital Status

If Other, please provide your marital status.

Employment Status

If Other, please provide your employment status.

Employer

Occupation

How were you referred to our office?

If Other, Please let us know how you were referred to our office.

Communication Preference

Eye History

Please check off any current conditions you suffer from

I stopped wearing glasses I stopped wearing contact lenses Headaches Glare/Light Sensitivity Tired Eyes Amblyopia (lazy eye) Burning Dryness Watery Eyes Eye Pain and/or Soreness Foreign Body Sensation Infection of Eye or Lid Itching Mucous Discharge Drooping eyelid(s) Redness Sandy or Gritty Feeling Strabismus (crossed eye) Blurred Vision at Distance Blurred Vision at Near Haloes Double Vision Floaters or Spots Fluctuating Vision Loss of Vision Loss of Side Vision

I stopped wearing glasses because:

Glasses History

Do you wear glasses?

Yes No

Contact Lens History

Do you wear contact lenses?

Yes No

Medical History

When, approximately, was your last eye exam?

Where did you get your last eye exam?

When, approximately, was your last physical exam?

Who is your primary care physician?

Do you drink alcohol?

Do you smoke?

Please list all medical conditions you have ever had (Diabetes, High blood pressure, Arthritis, etc.)

Please list all eye conditions you have ever had (Glaucoma, Cataract, Wandering or Lazy eye, Retinal detachment)

Please list any medical or eye conditions that run in your family (blood relatives) (Diabetes, High blood pressure, Cancer, Glaucoma, Macular degeneration, etc.)

Please list all hospital surgeries you have ever had:

Please list all prescription and over-the-counter medications you take and for what conditions

Please list all drug allergies you have

Please check off any current conditions you suffer from

Chronic fever, unexpected weight loss/gain, fatigue Ear/nose/throat problems ( eg. Hearing loss, sinus problems, sore throat) Heart problems (eg. Chest pain, irregular heart beat, swelling of feet, cold hands or feet) Respiratory problems (eg. Shortness of breath, wheezing, coughing) Gastrointestinal problems (eg. Heartburn, abdominal pain, diarrhea, vomiting) Genitourinary problems (eg. Painful urination, blood in urine, sex organ problems) Musculoskeletal problems (eg. Muscle aches, joint pain, swollen joints) Skin problems (eg. Rashes, excessive dryness, growths or lumps) Neurological problems (eg. Numbness, weakness, headaches, “blackouts”) Psychiatric problems (eg. Depression, anxiety) Endocrine problems (eg. Frequent urination, thirst, feeling hot or cold all the time) Blood/Lymph problems (eg. Bruising, weakness, unusual paleness, swollen glands) Immune problems (eg. Frequent infections, allergic reactions to foods, dust, pollens)

Primary Insurance

Please bring all insurance cards with you to your appointment.

Insurance Company Name

Insurance Company Phone Number

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

Secondary Insurance

If you have coverage through another plan/organization, please fill in the details below.

Insurance Company Name

Insurance Company Phone Number

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Insured's First Name

Insured's Last Name

Identification Number

Group Number

Insured's Date of Birth

Patient's Relation to Insured

If you have any comments you would like to add, please enter them here.

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Health Information Protection

I have read and agree to the Privacy Policy No

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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HOURS

Monday

9:00 am - 5:00 pm

Tuesday

9:00 am - 1:00 pm

Wednesday

Closed

Thursday

9:00 am - 5:00 pm

Friday

9:00 am - 5:00 pm

Saturday

8:00 am - 1:00 pm

Sunday

Closed

Locations

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Inspired Vision LLC

Address

1580 Makaloa St #950
Honolulu, HI 96814

Contact Information (808) 591-1566

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CONTACT US

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Email *

Phone *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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1580 Makaloa St #950 Honolulu, HI 96814
(808) 591-1566

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